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11 Burn Injury Nursing Care Plans (NCP)

A burn injury is damage to your body’s tissues caused by heat, chemicals, electricity, sunlight or radiation. Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns.

A major burn is a catastrophic injury, requiring painful treatment and long period of rehabilitation. It’s commonly fatal or permanently disfiguring and incapacitating (both emotionally and physically).

Nursing Care Plans

Here are 11 burn injury nursing care plans (NCP).

1. Impaired Physical Mobility

May be related to

  • Neuromuscular impairment, pain/discomfort, decreased strength and endurance
  • Restrictive therapies, limb immobilization; contractures

Possibly evidenced by

  • Reluctance to move/inability to purposefully move
  • Limited ROM, decreased muscle strength control and/or mass

Desired Outcomes

  • Maintain position of function as evidenced by absence of contractures.
  • Maintain or increase strength and function of affected and/or compensatory body part.
  • Verbalize and demonstrate willingness to participate in activities.
  • Demonstrate techniques/behaviors that enable resumption of activities.
Nursing Interventions Rationale
Maintain proper body alignment with supports or splints, especially for burns over joints. Promotes functional positioning of extremities and prevents contractures, which are more likely over joints.
Note circulation, motion, and sensation of digits frequently. Edema may compromise circulation to extremities, potentiating tissue necrosis and development of contractures.
Initiate the rehabilitative phase on admission. It is easier to enlist participation when patient is aware of the possibilities that exist for recovery.
Perform ROM exercises consistently, initially passive, then active. Prevents progressively tightening scar tissue and contractures; enhances maintenance of muscle and joint functioning and reduces loss of calcium from the bone.
Medicate for pain before activity or exercise. Reduces muscle and tissue stiffness and tension, enabling patient to be more active and facilitating participation.
Schedule treatments and care activities to provide periods of uninterrupted rest. Increases patient’s strength and tolerance for activity.
Encourage family/SO support and assistance with ROM exercises. Enables family/SO to be active in patient care and provides more consistent therapy.
Incorporate ADLs with physical therapy, hydrotherapy, and nursing care. Combining activities produces improved results by enhancing effects of each.
Encourage patient participation in all activities as individually able. Promotes independence, enhances self-esteem, and facilitates recovery process.
Incorporate ADLs with physical therapy, hydrotherapy, and nursing care. Combining activities produces improved results by enhancing effects of each.
Encourage patient participation in all activities as individually able. Promotes independence, enhances self-esteem, and facilitates recovery process.

2. Knowledge Deficit

May be related to

  • Lack of exposure/recall
  • Information misinterpretation; unfamiliarity with resources

Possibly evidenced by

  • Questions/request for information, statement of misconception
  • Inaccurate follow-through of instructions, development of preventable complications

Desired Outcomes

  • Verbalize understanding of condition, prognosis, and potential complications.
  • Verbalize understanding of therapeutic needs.
  • Correctly perform necessary procedures and explain reasons for actions.
  • Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions Rationale
Review condition, prognosis, and future expectations. Provides knowledge base from which patient can make informed choices.
Discuss patient’s expectations of returning home, to work, and to normal activities. Patient frequently has a difficult and prolonged adjustment after discharge. Problems often occur (sleep disturbances, nightmares, reliving the accident, difficulty with resumption of social interactions, intimacy and sexual activity, emotional lability) that interfere with successful adjustment to resuming normal life.
Review and have patient/SO demonstrate proper burn, skin-graft, and wound care techniques. Identify appropriate sources for outpatient care and supplies. Promotes competent self-care after discharge, enhancing independence.
Discuss skin care. Teach proper use of moisturizers, sunscreens, and anti-itching medications. Itching, blistering, and sensitivity of healing wounds or graft sites can be expected for an extended time, and injury can occur because of the fragility of the new tissue.
Explain scarring process and necessity for and proper use of pressure garments when used. Promotes optimal regrowth of skin, minimizing development of hypertrophic scarring and contractures and facilitating healing process. Note: Consistent use of the pressure garment over a long period can reduce the need for reconstructive surgery to release contractures and remove scars.
Encourage continuation of prescribed exercise program and scheduled rest periods. Maintains mobility, reduces complications, and prevents fatigue, facilitating recovery process.
Identify specific limitations of activity as individually appropriate. Imposed restrictions depend on severity and location of injury and stage of healing.
Emphasize importance of sustained intake of high-protein and high-calorie meals and snacks. Optimal nutrition enhances tissue regeneration and general feeling of well-being. Note: Patient often needs to increase caloric intake to meet calorie and protein needs for healing.
Review medications, including purpose, dosage, route, and expected and/or reportable side effects. Reiteration allows opportunity for patient to ask questions and be sure understanding is accurate.
Advise patient and/or SO of potential for exhaustion, boredom, emotional lability, adjustment problems. Provide information about possibility of discussion with appropriate professional counselors. Provides perspective to some of the problems patient and/or SO may encounter, and aids awareness that assistance is available when necessary.
Identify signs and symptoms requiring medical evaluation: inflammation, increase or changes in wound drainage, fever/chills; changes in pain characteristics or loss of mobility and/or function. Early detection of developing complications (infection, delayed healing) may prevent progression to more serious or life-threatening situations.
Stress importance of follow-up care and rehabilitation. Long-term support with continual reevaluation and changes in therapy is required to achieve optimal recovery.
Provide phone number for contact person. Provides easy access to treatment team to reinforce teaching, clarify misconceptions, and reduce potential for complications.
Ensure patient’s immunizations are current, especially tetanus. To prevent further injury.
Identify community resources: skin or wound care professionals, crisis centers, recovery groups, mental health, Red Cross, visiting nurse, Amblicab, homemaker service. Facilitates transition to home, provides assistance with meeting individual needs, and supports independence.

3. Disturbed Body Image

May be related to

  • Situational crisis: traumatic event, dependent patient role; disfigurement, pain

Possibly evidenced by

  • Negative feelings about body/self, fear of rejection/reaction by others
  • Focus on past appearance, abilities; preoccupation with change/loss
  • Change in physical capacity to resume role; change in social involvement

Desired Outcomes

  • Incorporate changes into self-concept without negating self-esteem.
  • Verbalize acceptance of self in situation.
  • Talk with family/SO about situation, changes that have occurred.
  • Develop realistic goals/plans for the future.
Nursing Interventions Rationale
Assess meaning of loss or change to patient and SO, including future expectations and impact of cultural or religious beliefs. Traumatic episode results in sudden, unanticipated changes, creating feelings of grief over actual or perceived losses. This necessitates support to work through to optimal resolution.
Acknowledge and accept expression of feelings of frustration, dependency, anger, grief, and hostility. Note withdrawn behavior and use of denial. Acceptance of these feelings as a normal response to what has occurred facilitates resolution. It is not helpful or possible to push patient before ready to deal with situation. Denial may be prolonged and be an adaptive mechanism because patient is not ready to cope with personal problems.
Set limits on maladaptive behavior. Maintain nonjudgmental attitude while giving care, and help patient identify positive behaviors that will aid in recovery. Patient and SO tend to deal with this crisis in the same way in which they have dealt with problems in the past. Staff may find it difficult and frustrating to handle behavior that is disrupting and not helpful to recuperation but should realize that the behavior is usually directed toward the situation and not the caregiver.
Be realistic and positive during treatments, in health teaching, and in setting goals within limitations. Enhances trust and rapport between patient and nurse.
Encourage patient and SO to view wounds and assist with care as appropriate. Promotes acceptance of reality of injury and of change in body and image of self as different.
Provide hope within parameters of individual situation; do not give false reassurance. Promotes positive attitude and provides opportunity to set goals and plan for future based on reality.
Assist patient to identify extent of actual change in appearance and body function. Helps begin process of looking to the future and how life will be different.
Give positive reinforcement of progress and encourage endeavors toward attainment of rehabilitation goals. Words of encouragement can support development of positive coping behaviors.
Show pictures or videos of burn care and/or other patient outcomes, being selective in what is shown as appropriate to the individual situation. Encourage discussion of feelings about what patient has seen. Allows patient and SO to be realistic in expectations. Also assists in demonstration of importance of and/or necessity for certain devices and procedures.
Encourage family interaction with each other and with rehabilitation team. To opens lines of communication and provides ongoing support for patient and family.
Provide support group for SO. Give information about how SO can be helpful to patient. Promotes ventilation of feelings and allows for more helpful responses to patient.
Role-play social situations of concern to patient. Prepares patient and SO for reactions of others and anticipates ways to deal with them.
Refer to physical and occupational therapy, vocational counselor, psychiatric counseling, clinical specialist psychiatric nurse, social services, and psychologist, as needed. Helpful in identifying ways/devices to regain and maintain independence. Patient may need further assistance to resolve persistent emotional problems.
Provide referral to reconstructive surgeon for the patient disfigured by burns. Reconstructive surgery can help patient gain self-esteem and confidence.
Provide through teaching and complete aftercare instructions for the patient. Stress importance of keeping the dressing dry and clean, elevating Reinforcing teaching can help patient achieve self-care.

4. Fear/Anxiety

May be related to

  • Situational crises: hospitalization/isolation procedures, interpersonal transmission and contagion, memory of the trauma experience, threat of death and/or disfigurement

Possibly evidenced by

  • Expressed concern regarding changes in life, fear of unspecific consequences
  • Apprehension; increased tension
  • Feelings of helplessness, uncertainty, decreased self-assurance
  • Sympathetic stimulation, extraneous movements, restlessness, insomnia

Desired Outcomes

  • Verbalize awareness of feelings and healthy ways to deal with them.
  • Report anxiety/fear reduced to manageable level.
  • Demonstrate problem-solving skills, effective use of resources.
Nursing Interventions Rationale
Give frequent explanations and information about care procedures. Repeat information as needed. Knowing what to expect usually reduces fear and anxiety, clarifies misconceptions, and promotes cooperation. Because of the shock of the initial trauma, many people do not recall information provided during that time.
Demonstrate willingness to listen and talk to patient when free of painful procedures. Helps patient and SO know that support is available and that healthcare provider is interested in the person, not just care of the burn.
Involve patient and SO in decision making process whenever possible. Provide time for questioning and repetition of proposed treatments. Promotes sense of control and cooperation, decreasing feelings of helplessness or hopelessness.
Assess mental status, including mood and affect, comprehension of events, and content of thoughts. Initially, patient may use denial and repression to reduce and filter information that might be overwhelming. Some patients display calm manner and alert mental status, representing a dissociation from reality, which is also a protective mechanism.
Investigate changes in mentation and presence of hypervigilance, hallucinations, sleep disturbances, nightmares, agitation, apathy, disorientation, and labile affect, all of which may vary from moment to moment. Indicators of extreme anxiety and delirium state in which patient is literally fighting for life. Although cause can be psychologically based, pathological life-threatening causes must be ruled out.
Provide constant and consistent orientation. Helps patient stay in touch with surroundings and reality.
Encourage patient to talk about the burn circumstances when ready. Patient may need to tell the story of what happened over and over to make some sense out of a terrifying situation. Adjustment to the impact of the trauma, grief over losses and disfigurement can easily lead to clinical depression, psychosis, and posttraumatic stress disorder (PTSD).
Explain to patient what happened. Provide opportunity for questions and give honest answers. Compassionate statements reflecting the reality of the situation can help patient and SO acknowledge that reality and begin to deal with what has happened.
Identify previous methods of coping and handling of stressful situations. Past successful behavior can be used to assist in dealing with the present situation.
Create a restful environment, use guided imagery and relaxation exercises. Patients experience severe anxiety associated with burn trauma and treatment. These interventions are soothing and helpful for positive outcomes.
Assist the family to express their feelings of grief and guilt. The family may initially be most concerned about patient’s dying and/or feel guilty, believing that in some way they could have prevented the incident.
Be empathic and nonjudgmental in dealing with patient and family. Family relationships are disrupted; financial, lifestyle or role changes make this a difficult time for those involved with patient, and they may react in many different ways.
Encourage family/SO to visit and discuss family happenings. Remind patient of past and future events. Maintains contact with a familiar reality, creating a sense of attachment and continuity of life.
Involve entire burn team in care from admission to discharge, including social worker and psychiatric resources. Provides a wider support system and promotes continuity of care and coordination of activities.

5. Impaired Skin Integrity

May be related to

  • Disruption of skin surface with destruction of skin layers (partial-/full-thickness burn) requiring grafting

Possibly evidenced by

  • Absence of viable tissue

Desired Outcomes

  • Wound Healing: Secondary Intention (NOC)
  • Demonstrate tissue regeneration.
  • Achieve timely healing of burned areas.
Nursing Interventions Rationale
Assess and document size, color, depth of wound, noting necrotic tissue and condition of surrounding skin. Provides baseline information about need for skin grafting and possible clues about circulation in area to support graft.
Provide appropriate burn care and infection control measures. Prepares tissues for grafting and reduces risk of infection/graft failure.
Maintain wound covering as indicated
Biosynthetic dressing (Biobrane); Nylon fabric and/or silicon membrane containing collagenous porcine peptides that adheres to wound surface until removed or sloughed off by spontaneous skin reepithelialization. Useful for eschar-free partial-thickness burns awaiting autografts because it can remain in place 2–3 wk or longer and is permeable to topical antimicrobial agents.
Synthetic dressings: DuoDerm; Hydroactive dressing that adheres to the skin to cover small partial-thickness burns and that interacts with wound exudate to form a soft gel that facilitates debridement.
Opsite, Acuderm. Thin, transparent, elastic, waterproof, occlusive dressing (permeable to moisture and air) that is used to cover clean partial-thickness wounds and clean donor sites.
Reduces swelling/limits risk of graft separation.
Elevate grafted area if possible. Maintain desired position and immobility of area when indicated. Movement of tissue under graft can dislodge it, interfering with optimal healing.
Maintain dressings over newly grafted area and/or donor site as indicated: mesh, petroleum, nonadhesive. Areas may be covered by translucent, nonreactive surface material (between graft and outer dressing) to eliminate shearing of new epithelium and protect healing tissue. The donor site is usually covered for 4–24 hr, then bulky dressings are removed and fine mesh gauze is left in place.
Keep skin free from pressure Promotes circulation and prevents ischemia or necrosis and graft failure.
Evaluate color of grafted and donor site(s); note presence or absence of healing. Evaluates effectiveness of circulation and identifies developing complications.
Wash sites with mild soap, rinse, and lubricate with cream several times daily after dressings are removed and healing is accomplished. Newly grafted skin and healed donor sites require special care to maintain flexibility.
Aspirate blebs under sheet grafts with sterile needle or roll with sterile swab. Fluid-filled blebs prevent graft adherence to underlying tissue, increasing risk of graft failure.
Prepare for/assist with surgical grafting or biological dressings: 
Homograft (allograft); Skin grafts obtained from living persons or cadavers are used as a temporary covering for extensive burns until person’s own skin is ready for grafting (test graft), to cover excised wounds immediately after escharotomy, or to protect granulation tissue.
Heterograft (xenograft, porcine); Skin grafts may be carried out with animal skin for the same purposes as homografts or to cover meshed autografts.
Cultured epithelial autograft (CEA); Skin graft obtained from uninjured part of patient’s own skin and prepared in a laboratory; may be full-thickness or partial-thickness. Note: This process takes 20–30 days from harvest to application. The new CEA sheets are 1–6 cell layers thick and thus are very fragile.
Artificial skin (Integra). Wound covering approved by the Food and Drug Administration (FDA) for full-thickness and deep partial-thickness burns. It provides a permanent, immediate covering that reproduces the skin’s normal functions and stimulates the regeneration of dermal tissue.

6. Imbalanced Nutrition

May be related to

  • Hypermetabolic state (can be as much as 50%–60% higher than normal proportional to the severity of injury)
  • Protein catabolism
  • Anorexia, restricted oral intake

Possibly evidenced by

  • Decrease in total body weight, loss of muscle mass/subcutaneous fat, and development of negative nitrogen balance

Desired Outcomes

  • Demonstrate nutritional intake adequate to meet metabolic needs as evidenced by stable weight/muscle-mass measurements, positive nitrogen balance, and tissue regeneration.
Nursing Interventions Rationale
Auscultate bowel sounds. Note hypoactive or absent bowel sounds. Ileus is often associated with postburn period but usually subsides within 36–48 hr, at which time oral feedings can be initiated.
Maintain strict calorie count. Weigh daily. Reassess percentage of open body surface area and wounds weekly. Appropriate guides to proper caloric intake include 25 kcal/kg body weight, plus 40 kcal per percentage of TBSA burn in the adult. As burn wound heals, percentage of burned areas is reevaluated to calculate prescribed dietary formulas, and appropriate adjustments are made.
Monitor muscle mass and subcutaneous fat as indicated. Indirect calorimetry, if available, may be useful in more accurately estimating body reserves or losses and effectiveness of therapy.
Provide small, frequent meals and snacks. Helps prevent gastric distension or discomfort and may enhance intake.
Encourage patient to view diet as a treatment and to make food or beverage choices high in calories and protein. Calories and proteins are needed to maintain weight, meet metabolic needs, and promote wound healing.
Ascertain food likes and dislikes. Encourage SO to bring food from home, as appropriate. Provides patient or SO sense of control; enhances participation in care and may improve intake.
Encourage patient to sit up for meals and visit with others. Sitting helps prevent aspiration and aids in proper digestion of food. Socialization promotes relaxation and may enhance intake.
Provide oral hygiene before meals. Clean mouth and clean palate enhances taste and helps promote a good appetite.
Insert nasogastric tube, as indicated. To decompress the stomach and avoid aspiration of stomach contents.
Perform fingerstick glucose, urine testing as indicated. Monitors for development of hyperglycemia related to hormonal changes or demands or use of hyperalimentation to meet caloric needs.
Refer to dietitian or nutrition support team. Useful in establishing individual nutritional needs (based on weight and body surface area of injury) and identifying appropriate routes.
Provide diet high in calories or protein with trace elements and vitamin supplements. Calories (3000–5000 per day), proteins, and vitamins are needed to meet increased metabolic needs, maintain weight, and encourage tissue regeneration. Note: Oral route is preferable once GI function returns.
Insert and maintain small feeding tube for enteral feedings and supplements if needed. Provides continuous supplemental feedings when patient is unable to consume total daily calorie requirements orally. Note: Continuous tube feeding during the night increases calorie intake without decreasing appetite and oral intake during the day.
Administer parenteral nutrition solutions containing vitamins and minerals, as indicated. Total parenteral nutrition (TPN) maintains nutritional intake and meets metabolic needs in presence of severe complications or sustained esophageal or gastric injuries that do not permit enteral feedings.
Monitor laboratory studies: serum albumin,
prealbumin, Cr, transferrin, urine urea nitrogen.
Indicators of nutritional needs and adequacy of diet/therapy.
Administer insulin as indicated. Elevated serum glucose levels may develop because of stress response to injury, high caloric intake, pancreatic fatigue.

7. Ineffective Tissue Perfusion

Risk factors may include

  • Reduction/interruption of arterial/venous blood flow, e.g., circumferential burns of extremities with resultant edema
  • Hypovolemia

Desired Outcomes

  • Maintain palpable peripheral pulses
Nursing Interventions Rationale
Assess color, sensation, movement, peripheral pulses, and capillary refill on extremities with circumferential burns. Compare with findings of unaffected limb. Edema formation can readily compress blood vessels, thereby impeding circulation and increasing venous stasis or edema. Comparisons with unaffected limbs aid in differentiating localized versus systemic problems (hypovolemia or decreased cardiac output).
Elevate affected extremities, as appropriate. Remove jewelry or arm bands Avoid taping around a burned area. Promotes systemic circulation and venous return that may reduce edema or other deleterious effects of constriction of edematous tissues. Prolonged elevation can impair arterial perfusion if blood pressure (BP) falls or tissue pressures rise excessively.
Obtain BP in unburned extremity when possible. Remove BP cuff after each reading, as indicated. If BP readings must be obtained on an injured extremity, leaving the cuff in place may increase edema formation and reduce perfusion, and convert partial thickness burn to a more serious injury.
Investigate reports of deep or throbbing ache, numbness. Indicators of decreased perfusion and/or increased pressure within enclosed space, such as may occur with a circumferential burn of an extremity (compartment syndrome).
Encourage active ROM exercises of unaffected body parts. Promotes local and systemic circulation.
Investigate irregular pulses Cardiac dysrhythmias can occur as a result of electrolyte shifts, electrical injury, or release of myocardial depressant factor, compromising cardiac output.
Maintain fluid replacement per protocol. Maximizes circulating volume and tissue perfusion.
Monitor electrolytes, especially sodium, potassium, and calcium. Administer replacement therapy as indicated. Losses or shifts of these electrolytes affect cellular membrane potential and excitability, thereby altering myocardial conductivity, potentiating risk of dysrhythmias, and reducing cardiac output and tissue perfusion.
Avoid use of IM/SC injections. Altered tissue perfusion and edema formation impair drug absorption. Injections into potential donor sites may render them unusable because of hematoma formation.
Measure intracompartmental pressures as indicated. Ischemic myositis may develop because of decreased perfusion.
Assist and prepare for escharotomy or fasciotomy, as indicated. Enhances circulation by relieving constriction caused by rigid, nonviable tissue (eschar) or edema formation.

8. Acute Pain

May be related to

  • Destruction of skin/tissues; edema formation
  • Manipulation of injured tissues, e.g., wound debridement

Possibly evidenced by

  • Reports of pain
  • Narrowed focus, facial mask of pain
  • Alteration in muscle tone; autonomic responses
  • Distraction/guarding behaviors; anxiety/fear, restlessness

Desired Outcomes

  • Report pain reduced/controlled.
  • Display relaxed facial expressions/body posture.
  • Participate in activities and sleep/rest appropriately.
Nursing Interventions Rationale
Cover wounds as soon as possible unless open-air exposure burn care method required. Temperature changes and air movement can cause great pain to exposed nerve endings.
Elevate burned extremities periodically. Elevation may be required initially to reduce edema formation; thereafter, changes in position and elevation reduce discomfort and risk of joint contractures.
Provide bed cradle as indicated. Elevation of linens off wounds may help reduce pain.
Wrap digits or extremities in position of function (avoiding flexed position of affected joints) using splints and foot boards as necessary. Position of function reduces deformities or contractures and promotes comfort. Although flexed position of injured joints may feel more comfortable, it can lead to flexion contractures.
Change position frequently and assist with active and passive ROM as indicated. Movement and exercise reduce joint stiffness and muscle fatigue, but type of exercise depends on location and extent of injury.
Maintain comfortable environmental temperature, provide heat lamps, heat retaining body coverings. Temperature regulation may be lost with major burns. External heat sources may be necessary to prevent chilling.
Assess reports of pain, noting location and character and intensity (0–10 scale). Pain is nearly always present to some degree because of varying severity of tissue involvement and destruction but is usually most severe during dressing changes and debridement. Changes in location, character, intensity of pain may indicate developing complications (limb ischemia) or herald improvement and/or return of nerve function and sensation.
Provide medication and/or place in hydrotherapy (as appropriate) before performing dressing changes and debridement. Reduces severe physical and emotional distress associated with dressing changes and debridement.
Encourage expression of feelings about pain. Verbalization allows outlet for emotions and may enhance coping mechanisms.
Involve patient in determining schedule for activities, treatments, drug administration. Enhances patient’s sense of control and strengthens coping mechanisms.
Explain procedures and provide frequent information as appropriate, especially during wound debridement. Empathic support can help alleviate pain and/or promote relaxation. Knowing what to expect provides opportunity for patient to prepare self and enhances sense of control.
Provide basic comfort measures: massage of uninjured areas, frequent position changes. Promotes relaxation; reduces muscle tension and general fatigue.
Encourage use of stress management techniques: progressive relaxation, deep breathing, guided imagery, and visualization. Refocuses attention, promotes relaxation, and enhances sense of control, which may reduce pharmacological dependency.
Provide diversional activities appropriate for age and condition. Helps lessen concentration on pain experience and refocus attention.
Promote uninterrupted sleep periods. Sleep deprivation can increase perception of pain/reduce coping abilities.
Administer analgesics (narcotic and nonnarcotic) as indicated: morphine; fentanyl (Sublimaze, Ultiva); hydrocodone (Vicodin, Hycodan); oxycodone(OxyContin, Percocet). The burned patient may require around-the-clock medication and dose titration. IV method is often used initially to maximize drug effect. Concerns of patient addiction or doubts regarding degree of pain experienced are not valid during emergent/acute phase of care, but narcotics should be decreased as soon as feasible and alternative methods for pain relief initiated.

9. Risk for Infection

Risk factors may include

  • Inadequate primary defenses: destruction of skin barrier, traumatized tissues
  • Inadequate secondary defenses: decreased Hb, suppressed inflammatory response
  • Environmental exposure, invasive procedures

Desired Outcomes

  • Achieve timely wound healing free of purulent exudate and be afebrile.
Nursing Interventions Rationale
Implement appropriate isolation techniques as indicated Dependent on type or extent of wounds and the choice of wound treatment (open versus closed), isolation may range from simple wound and/or skin to complete or reverse to reduce risk of cross contamination and exposure to multiple bacterial flora.
Emphasize and model good handwashing technique for all individuals coming in contact with patient. Prevents cross contamination; reduces risk of acquired infection.
Use gowns, gloves, masks, and strict aseptic technique during direct wound care and provide sterile or freshly laundered bed linens or gowns. Prevents exposure to infectious organisms.
Monitor and/or limit visitors, if necessary. If isolation is used, explain procedure to visitors. Supervise visitor adherence to protocol as indicated. Prevents cross-contamination from visitors. Concern for risk of infection should be balanced against patient’s need for family support and socialization.
Shave or clip all hair from around burned areas to include a 1-in border (excluding eyebrows). Shave facial hair (men) and shampoo head daily. Opportunistic infections (yeast) frequently occur because of depression of the immune system and/or proliferation of normal body flora during systemic antibiotic therapy.
Examine unburned areas (such as groin, neck creases, mucous membranes) and vaginal discharge routinely. Eyes may be swollen shut and/or become infected by drainage from surrounding burns. If lids are burned, eye covers may be needed to prevent corneal damage.
Provide special care for eyes: use eye covers and tear formulas as appropriate. Prevents adherence to surface it may be touching and encourages proper healing. Note: Ear cartilage has limited circulation and is prone to pressure necrosis.
Prevent skin-to-skin surface contact (wrap each burned finger or toe separately; do not allow burned ear to touch scalp). Identifies presence of healing (granulation tissue) and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury. Note: A strong sweet, musty smell at a graft site is indicative of Pseudomonas.
Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Note: Changes in sensorium, bowel habits, and respiratory rate usually precede fever and alteration of laboratory studies.
Monitor vital signs for fever, increased respiratory rate and depth in association with changes in sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria. Water softens and aids in removal of dressings and eschar (slough layer of dead skin or tissue). Sources vary as to whether bath or shower is best. Bath has advantage of water providing support for exercising extremities but may promote cross-contamination of wounds. Showering enhances wound inspection and prevents contamination from floating debris.
Remove dressings and cleanse burned areas in a hydrotherapy or whirlpool tub or in a shower stall with handheld shower head. Maintain temperature of water at 100°F (37.8°C). Wash areas with a mild cleansing agent or surgical soap. Early excision is known to reduce scarring and risk of infection, thereby facilitating healing.
Debride necrotic or loose tissue (including ruptured blisters) with scissors and forceps. Do not disturb intact blisters if they are smaller than 1–2 cm, do not interfere with joint function, and do not appear infected. Promotes healing. Prevents autocontamination. Small, intact blisters help protect skin and increase rate of re-epithelialization unless the burn injury is the result of chemicals (in which case fluid contained in blisters may continue to cause tissue destruction).
Photograph wound initially and at periodic intervals. Provides baseline and documentation of healing process.
Administer topical agents as indicated: The following agents help control bacterial growth and prevent drying of wound, which can cause further tissue destruction.
Silver sulfadiazine (Silvadene); Broad-spectrum antimicrobial that is relatively painless but has intermediate, somewhat delayed eschar penetration. May cause rash or depression of WBCs.
Mafenide acetate (Sulfamylon); Antibiotic of choice with confirmed invasive burn-wound infection. Useful against Gram-negative or Gram-positive organisms. Causes burning or pain on application and for 30 min thereafter. Can cause rash, metabolic acidosis, and decreased Paco2.
Silver nitrate; Effective against Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa, but has poor eschar penetration, is painful, and may cause electrolyte imbalance. Dressings must be constantly saturated. Product stains skin/surfaces black.
Bacitracin; Effective against Gram-positive organisms and is generally used for superficial and facial burns.
Povidone-iodine (Betadine); Broad-spectrum antimicrobial, but is painful on application, may cause metabolic acidosis or increased iodine absorption, and damage fragile tissues.
Hydrogels: Transorb, Burnfree. Useful for partial- and full-thickness burns; filling dead spaces, rehydrating dry wound beds, and promoting autolytic debridement. May be used when infection is present.Systemic antibiotics are given to control general infections identified by culture and sensitivity. Subeschar clysis has been found effective against pathogens in granulated tissues at the line of demarcation between viable or nonviable tissue, reducing risk of sepsis.
Administer other medications as appropriate: Subeschar clysis or systemic antibiotics; Tetanus toxoid or clostridial antitoxin, as appropriate. Tissue destruction and altered defense mechanisms increase risk of developing tetanus or gas gangrene, especially in deep burns such as those caused by electricity.
Place IV and/or invasive lines in non burned area. Decreased risk of infection at insertion site with possibility of progression to septicemia.
Obtain routine cultures and sensitivities of wounds and/or drainage. Allows early recognition and specific treatment of wound infection.

10. Risk for Deficient Fluid Volume

Risk factors may include

  • Loss of fluid through abnormal routes, e.g., burn wounds
  • Increased need: hypermetabolic state, insufficient intake
  • Hemorrhagic losses

Desired Outcomes

  • Demonstrate improved fluid balance as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes.
Nursing Interventions Rationale
Monitor vital signs, central venous pressure (CVP). Note capillary refill and strength of peripheral pulses. Serves as a guide to fluid replacement needs and assesses cardiovascular response. Note: Invasive monitoring is indicated for patients with major burns, smoke inhalation, or preexisting cardiac disease, although there is an associated increased risk of infection, necessitating careful monitoring and care of insertion site.
Monitor urinary output and specific gravity. Observe urine color and Hematest as indicated. Generally, fluid replacement should be titrated to ensure average urinary output of 30–50 mL/hr (in the adult). Urine can appear red to black (with massive muscle destruction) because of presence of blood and release of myoglobin. If gross myoglobinuria is present, minimum urinary output should be 75–100 mL/hr to reduce risk of tubular damage and renal failure.
Estimate wound drainage and insensible losses. Increased capillary permeability, protein shifts, inflammatory process, and evaporative losses greatly affect circulating volume and urinary output, especially during initial 24–72 hr after burn injury.
Maintain cumulative record of amount and types of fluid intake. Massive or rapid replacement with different types of fluids and fluctuations in rate of administration require close tabulation to prevent constituent imbalances or fluid overload.
Weigh daily. Fluid replacement formulas partly depend on admission weight and subsequent changes. A 15%–20% weight gain can be anticipated in the first 72 hr during fluid replacement, with return to pre-burn weight approximately 10 days after burn.
Measure circumference of burned extremities as indicated. May be helpful in estimating extent of edema and fluid shifts affecting circulating volume and urinary output.
Investigate changes in mentation. Deterioration in the level of consciousness may indicate inadequate circulating volume and reduced cerebral perfusion.
Observe for gastric distension, hematemesis, tarry stools. Hematest nasogastric (NG) drainage and stools periodically. Stress (Curling’s) ulcer occurs in up to half of all severely burned patients and can occur as early as the first week. Patients with burns more than 20% TBSA are at risk for mucosal bleeding in the gastrointestinal (GI) tract during the acute phase because of decreased splanchnic blood flow and reflex paralytic ileus.
Insert and maintain indwelling urinary catheter. Allows for close observation of renal function and prevents urinary retention. Retention of urine with its by-products of tissue-cell destruction can lead to renal dysfunction and infection.
Insert and maintain large-bore IV catheter(s). Accommodates rapid infusion of fluids.
Administer calculated IV replacement of fluids, electrolytes, plasma, albumin. Fluid resuscitation replaces lost fluids and electrolytes and helps prevent complications (shock, acute tubular necrosis). Replacement formulas vary but are based on extent of injury, amount of urinary output, and weight. Note: Once initial fluid resuscitation has been accomplished, a steady rate of fluid administration is preferred to boluses, which may increase interstitial fluid shifts and cardiopulmonary congestion.
Monitor laboratory studies: Hb/Hct, electrolytes, random urine sodium. Identifies blood loss or RBC destruction and fluid and electrolyte replacement needs. Urine sodium less than 10 mEq/L suggests inadequate fluid resuscitation. Note: During first 24 hr after burn, hemoconcentration is common because of fluid shifts into the interstitial space.
Administer medications as indicated:
Diuretics: mannitol (Osmitrol); May be indicated to enhance urinary output and clear tubules of debris and prevent necrosis if acute renal failure (ARF) is present.
Potassium; Although hyperkalemia often occurs during first 24–48 hr (tissue destruction), subsequent replacement may be necessary because of large urinary losses.
Antacids: calcium carbonate (Titralac), magaldrate (Riopan); Antacids may reduce gastric acidity;
histamine inhibitors: cimetidine (Tagamet) and ranitidine (Zantac). histamine inhibitors decrease production of hydrochloric acid to reduce risk of gastric irritation and bleeding.
Add electrolytes to water used for wound debridement, as indicated. Washing solution that approximates tissue fluids may minimize osmotic fluid shifts.

11. Risk for Ineffective Airway Clearance

Risk factors may include

  • Tracheobronchial obstruction: mucosal edema and loss of ciliary action (smoke inhalation); circumferential full-thickness burns of the neck, thorax, and chest, with compression of the airway or limited chest excursion
  • Trauma: direct upper-airway injury by flame, steam, hot air, and chemicals/gases
  • Fluid shifts, pulmonary edema, decreased lung compliance

Desired Outcomes

  • Demonstrate clear breath sounds, respiratory rate within normal range, be free of dyspnea/cyanosis.
Nursing Interventions Rationale
Immediately assess the patient’s airway, breathing, and circulation. Be especially alert for signs of smoke inhalation, and pulmonary damage: singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum. Exposure to materials burn can cause inhalation injury.
Draw blood samples for complete blood count, type and crossmatch and electrolyte glucose, blood urea nitrogen, creatinine, and ABG levels. To have baseline data and may indicate choice of next steps of treatment.
Obtain history of injury. Note presence of preexisting respiratory conditions, history of smoking. Causative burning agent, duration of exposure, and occurrence in closed or open space predict probability of inhalation injury. Type of material burned (wood, plastic, wool, and so forth) suggests type of toxic gas exposure. Preexisting conditions increase the risk of respiratory complications.
Assess gag and swallow reflexes; note drooling, inability to swallow, hoarseness, wheezy cough. Suggestive of inhalation injury.
Monitor respiratory rate, rhythm, depth: note presence of pallor or cyanosis and carbonaceous or pink-tinged sputum. Tachypnea, use of accessory muscles, presence of cyanosis, and changes in sputum suggest developing respiratory distress or pulmonary edema and need for medical intervention.
Auscultate lungs, noting stridor, wheezing or crackles, diminished breath sounds, brassy cough. Airway obstruction and/or respiratory distress can occur very quickly or may be delayed, e.g., up to 48 hr after burn.
Note presence of pallor or cherry-red color of unburned skin. Suggests presence of hypoxemia or carbon monoxide.
Investigate changes in behavior or mentation: restlessness, agitation, altered LOC. Although often related to pain, changes in consciousness may reflect developing or worsening hypoxia.
Monitor 24-hr fluid balance, noting variations/changes. Fluid shifts or excess fluid replacement increases risk of pulmonary edema. Note: Inhalation injury increases fluid demands as much as 35% or more because of obligatory edema.
Elevate head of bed. Avoid use of pillow under head, as indicated. Promotes optimal lung expansion or respiratory function. When head or neck burns are present, a pillow can inhibit respiration, cause necrosis of burned ear cartilage, and promote neck contractures.
Encourage coughing or deep breathing exercises and frequent position changes. Promotes lung expansion, mobilization and drainage of secretions.
Suction (if necessary) with extreme care, maintaining sterile technique. Helps maintain clear airway, but should be done cautiously because of mucosal edema and inflammation. Sterile technique reduces risk of infection.
Promote voice rest, but assess ability to speak and/or swallow oral secretions periodically. Increasing hoarseness or decreased ability to swallow suggests increasing tracheal edema and may indicate need for prompt intubation.
Administer humidified oxygen via appropriate mode (face mask). O2 corrects hypoxemia and acidosis. Humidity decreases drying of respiratory tract and reduces viscosity of sputum.
Monitor and graph serial ABGs or pulse oximetry. Baseline is essential for further assessment of respiratory status and as a guide to treatment. Pao2 less than 50, Paco2 greater than 50, and decreasing pH reflect smoke inhalation and developing pneumonia or ARDS.
Review serial chest x-rays. Changes reflecting atelectasis and/or pulmonary edema may not occur for 2–3 days after burn
Provide and assist with chest physiotherapy and incentive spirometry. Chest physiotherapy drains dependent areas of the lung, and incentive spirometry may be done to improve lung expansion, thereby promoting respiratory function and reducing atelectasis.
Prepare and assist with intubation or tracheostomy, as indicated Intubation or mechanical support is required when airway edema or circumferential burn injury interferes with respiratory function or oxygenation.

Other Possible Nursing Care Plans

  • Post-trauma syndrome—may be related to life-threatening event, possibly evidenced by reexperiencing the event, repetitive dreams/nightmares, emotional numbness, and sleep disturbance.
  • Ineffective protection—may be related to extremes of age, inadequate nutrition, anemia, impaired immune system, possibly evidenced by impaired healing, deficient immunity, fatigue, anorexia.
  • Deficient diversional activity—may be related to long-term hospitalization, frequent or lengthy treatments, and physical limitations, possibly evidenced by expressions of boredom, restlessness, withdrawal and requests for something to do.
  • Risk for delayed development—risk factors may include effects of physical disability, separation from SO, and environmental deficiencies.

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